A medication error is one of the most common causes of patients complications or death in healthcare facilities. In the United States, 7,000 out of 9,000 patients die because of medication errors each year. Known factors are generally divided into four groups - human factor, intervention, technical factor, and system. Our study includes 17 studies from the OVID, Web of Science, Scopus, and EBSCO databases, in the range of 2015-2020. After a selection of professional publications, 2 categories were created - factors leading to medication errors and interventions to reduce medication error and testing their effectiveness. It has been found that human factor always plays a role, often supported by a poorly set-up system. The most mistakes are made in documentation, administration technique or accidental interchange of patients. The most frequently mentioned factors include nurses overload, high number of critically ill patients, interruptions in the preparation or in the administration of medications, absence of the adverse event reporting system, non-compliance with guidelines, fear, and anxiety. Another evidence of medication error is in the application of intravenous drugs, where an interchange of drugs or patients due to interruption occurs as well. Sufficient education of nurses and an adequate system of preparation and administration of drugs, for example using bar codes, are considered as an appropriate intervention.

• Klíčová slova
• Drug administration, drug preparation, factors of medication error, intervention, medication error,
• MeSH
• kritický stav MeSH
• léčivé přípravky * MeSH
• lidé MeSH
• medikační omyly * prevence a kontrola   MeSH
• poskytování zdravotní péče MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• Názvy látek
• léčivé přípravky * MeSH

1. Older people have substantial interindividual variability in health, disability, age-related changes, polymorbidity, and associated polypharmacy, making generalization of prescribing recommendations difficult. 2. Medication use in older adults is often inappropriate and erroneous, partly because of the complexities of prescribing and partly because of many patient, provider, and health system factors that substantially influence the therapeutic value of medications in aged people. 3. A high prevalence of medication errors in older adults results on the one hand from accumulation of factors that contribute to medication errors in all age groups, such as polypharmacy, polymorbidity, enrollment in several disease-management programmes, and fragmentation of care. On the other hand, specific geriatric aspects play a role in these medication errors; these include age-related pharmacological changes, lack of specific evidence on the efficacy and safety of medications, underuse of comprehensive geriatric assessment, less availability of drug formulations offering geriatric doses, and inadequate harmonization of geriatric recommendations across Europe. 4. The dearth of geriatric clinical pharmacology and clinical pharmacy services compounds the difficulties. 5. There are gaps in research and clinical practice that lead to frequent medication errors in older adults, which must be solved by future studies and by regulatory measures in order to support errorless and appropriate use medications in these people.

• MeSH
• geriatrické hodnocení MeSH
• lékařská praxe - způsoby provádění organizace a řízení   normy   MeSH
• lékové předpisy normy   MeSH
• lidé MeSH
• medikační omyly prevence a kontrola   MeSH
• polypharmacy * MeSH
• rizikové faktory MeSH
• rozhodování MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Check Tag
• lidé MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

INTRODUCTION: Healthcare is inherently associated with a risk to patient health. One risk is associated with medication-related errors, which are commonly reported adverse events. By analyzing the root causes of medication errors, effective preventive measures can be proposed to reduce their likelihood. This study aimed to identify the reasons of medication administration errors, determine the number of medication administration errors reported, and describe the barriers hindering reporting. METHODOLOGY: The study used a standardized Questionnaire Medication Administration Error Survey (MAE survey) that was quantitatively analyzed. The study involved 112 nurses from four hospitals in the South Bohemian Region. RESULTS: Risk factors that increase the likelihood of medication administration errors include similarity of drug names (3.7 ± 1.3) and packaging (3.9 ± 1.5), frequent prescription changes for patients (3.2 ± 1.5), illegibility of written prescriptions (3.1 ± 1.6), a lack of clarity of medical records (2.6 ± 1.5). Only a proportion of medication administration errors are reported by nurses (16% to 21%). The reluctance of nurses to report medication administration errors is linked to fear of being blamed for the deterioration of the patients health (3.3 ± 1.7), fear of the doctors reaction to a medication administration error (2.6 ± 1.4), and repressive responses from hospital management to reported misconduct (2.9 ± 1.5). CONCLUSION: Measures to reduce the likelihood of medication administration errors include building a non-punitive system for reporting adverse events and medication errors, introducing electronic prescription systems, promoting open communication within the team, involving clinical pharmacists in the pharmacotherapy process, and regular comprehensive training of nursing staff.

• Klíčová slova
• administration of drugs, medication error, nurse, reporting of adverse events,
• MeSH
• farmaceuti MeSH
• lidé MeSH
• medikační omyly prevence a kontrola   MeSH
• nemocnice MeSH
• personál sesterský nemocniční * MeSH
• průzkumy a dotazníky MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

AIM: The aim was to analyze selected studies on rationed nursing care as one of the indicators that influence the occurrence of medication errors. METHODS: A descriptive review study. Articles and studies were searched in the following selected electronic databases: EBSCO (Academic Search Ultimate, Academic Search Complete), CINAHL Plus with Full Text, MEDLINE Complete, ScienceDirect and Central & Eastern European Academic Source. The search for relevant sources was based on the following English keywords: unfinished care, omitted care, rationing care, missed care, nursing care, medication errors. RESULTS: Total of 86 contributions found. After duplicit and irrelevant publications were the analysis comprised 8 primary studies and 2 systematic reviews. The studies were concerned with rationed or otherwise defined non-standard nursing care not merely related to medication errors. Each study described selected activities most frequently omitted by nurses with respect to medication: assessment of drug efficacy, medication errors, administration of incorrect drugs or doses, wrong time of administration, high-risk drug protocols and adhering to rules with each administration. The most frequently reported factor influencing the occurrence of missed care was understaffing and the related number of patients per nurse, resulting in a lack of time for selected patient activities. CONCLUSION: Despite difference in methods, all studies consistently claimed that rationed, unfinished, missed or omitted nursing care has or may have a negative impact on both patients and nurses. Some of the recommendations were increasing the number of nurses, improving team collaboration and work organization including setting systemic and preventive measures.

• Klíčová slova
• medication error, missed care, nursing care, omitted care, rationing care, unfinished care,
• MeSH
• lidé MeSH
• medikační omyly * MeSH
• ošetřovatelská péče * MeSH
• přidělování zdravotní péče * MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH

OBJECTIVE: To analyze the types and reasons of medication errors, committed by health care professionals, which led to toxicological consultations at the Czech Toxicological Information Centre (TIC). METHODS: Inquiries arising from medication errors for 2000-2010 were extracted and evaluated from the database of the TIC, recording the consultations of poisonings due to drugs, household products, plants, and mushrooms. RESULTS: From a total of 44,344 calls concerning pharmaceuticals, 215 (0.5%) were denoted by the caller as medication errors; 130 involved children (90 below 5 years of age) and 85 involved adults (30-60 years of age). The most common errors were: improper dosage (60.9%), wrong medication (19.3%), or erroneous route of administration (12.9%). The most frequent medication errors appeared using drugs affecting the nervous system (psycholeptics and antiepileptics), antibiotics, and drugs affecting the respiratory system. Nurses administering the drugs were responsible for 43.0%, physicians prescribing the drugs for 36.8%, and pharmacists dispensing the drugs for 20.2% of the errors. Of 25 patients with severe drug intoxications, 60.0% were children under 5 years of age treated with pharmaceuticals affecting the CNS, and 28.0% patients over 60 years of age with chronic application of theophylline, digoxin, or lithium. CONCLUSIONS: The trend in medication errors has remained relatively stable over the past 11 years. The analysis of medication errors shows two high-risk categories: children of less than 5 years of age, in whom the dose was not correctly adjusted, and elderly people with chronic medication and insufficient control of their medication level. Therefore, the measures for risk reduction should focus primarily on them.

• MeSH
• dítě MeSH
• lidé MeSH
• medikační omyly statistika a číselné údaje   MeSH
• předškolní dítě MeSH
• senioři MeSH
• věkové faktory * MeSH
• Check Tag
• dítě MeSH
• lidé MeSH
• předškolní dítě MeSH
• senioři MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH

Case (description): A 74 years old Caucasian suffering from chronic kidney disease presented with progressive asthenia and diffuse myalgia. It was revealed that the patient used three different rosuvastatin-containing preparations in a total daily dose of 120 mg for 76 days. Laboratory investigations revealed a marked elevation of serum urea, creatinine, myoglobin, creatine kinase (CK) and transaminases. Two serious medication errors have been identified as possible major factors that synergistically contributed to the development of rosuvastatin-induced rhabdomyolysis. First, 40 mg of rosuvastatin dose was prescribed to the patient, although the estimation of glomerular filtration rate (eGFR) declined below 40 ml/min/1.73 m2. Moreover, the patient used 3 different rosuvastatin formulations simultaneously in a total dose of 120 mg/day. The heterozygous CYP2C9*1/*3 genotype and warfarin co-administration could further contribute to the development of rhabdomyolysis. A number of preventive measures, notably in drug policy, are suggested to overcome unintended intoxications. Conclusion: Rosuvastatin-induced myopathy is a rare, but serious adverse effect. This case report highlights the need for a proper treatment and dose adjustment during chronic medical therapy, the need for adequate patient education and application of adequate drug policy measures in the era of fragmented health care delivery and polypragmasia.

• Klíčová slova
• adverse effects, medication errors, rhabdomyolysis, rosuvastatin,
• MeSH
• lidé MeSH
• medikační omyly * MeSH
• rhabdomyolýza chemicky indukované   MeSH
• rosuvastatin kalcium škodlivé účinky   MeSH
• senioři MeSH
• statiny škodlivé účinky   MeSH
• Check Tag
• lidé MeSH
• senioři MeSH
• Publikační typ
• časopisecké články MeSH
• kazuistiky MeSH
• Názvy látek
• rosuvastatin kalcium MeSH
• statiny MeSH

BACKGROUND: Medication administration errors (MAE) are a worldwide issue affecting the safety of hospitalized patients. Through the early identification of potential causes, it is possible to increase the safety of medication administration (MA) in clinical nursing. The study aimed to identify potential risk factors affecting drug administration in inpatient wards in the Czech Republic. MATERIAL AND METHODS: A descriptive correlation study through a non-standardized questionnaire was used. Data were collected from September 29 to October 15, 2021, from nurses in the Czech Republic. For statistical analysis, the authors used SPSS vers. 28 (IBM Corp., Armonk, NY, USA). RESULTS: The research sample consisted of 1205 nurses. The authors found that there was a statistically significant relationship between nurse education (p = 0.05), interruptions, preparation of medicines outside the patient rooms (p < 0.001), inadequate patient identification (p < 0.01), large numbers of patients assigned per nurse (p < 0.001), use of team nursing care and administration of generic substitution and an MAE. CONCLUSIONS: The results of the study point to the weaknesses of medication administration in selected clinical departments in hospitals. The authors found that several factors, such as high patient ratio per nurse, lack of patient identification, and interruption during medication preparation of nurses, can increase the prevalence of MAE. Nurses who have completed MSc and PhD education have a lower incidence of MAE. More research is needed to identify other causes of medication administration errors. Improving the safety culture is the most critical challenge for today's healthcare industry. Education for nurses can be an effective way to reduce MAEs by enhancing their knowledge and skills, mainly focusing on increasing adherence to safe medication preparation and administration and a better understanding of medication pharmacodynamics. Med Pr. 2023;74(2):85-92.

• Klíčová slova
• drug, errors, medication administration, nursing, patient safety, safety management,
• MeSH
• korelace dat MeSH
• léčivé přípravky MeSH
• lidé MeSH
• medikační omyly * prevence a kontrola   MeSH
• průzkumy a dotazníky MeSH
• zpráva o sobě MeSH
• Check Tag
• lidé MeSH
• Publikační typ
• časopisecké články MeSH
• Názvy látek
• léčivé přípravky MeSH

This study aimed to analyse medication errors committed by health care professionals leading to toxicological consultations at the Czech Toxicological Information Centre and to identify the categories of special concern for further interventions of health care quality experts.

• MeSH
• databáze faktografické statistika a číselné údaje   MeSH
• dítě MeSH
• dospělí MeSH
• kojenec MeSH
• léky na předpis toxicita   MeSH
• lidé středního věku MeSH
• lidé MeSH
• medikační omyly klasifikace   statistika a číselné údaje   MeSH
• mladiství MeSH
• nežádoucí účinky léčiv epidemiologie   MeSH
• novorozenec MeSH
• předškolní dítě MeSH
• retrospektivní studie MeSH
• senioři MeSH
• urgentní zdravotnické služby statistika a číselné údaje   MeSH
• věkové faktory MeSH
• zdravotnický personál statistika a číselné údaje   MeSH
• Check Tag
• dítě MeSH
• dospělí MeSH
• kojenec MeSH
• lidé středního věku MeSH
• lidé MeSH
• mladiství MeSH
• mužské pohlaví MeSH
• novorozenec MeSH
• předškolní dítě MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• Geografické názvy
• Česká republika MeSH
• Názvy látek
• léky na předpis MeSH

CONTEXT: Criteria for potentially inappropriate medication use among elderly patients have been used in the past decade in large US epidemiological surveys to identify populations at risk and specifically target risk-management strategies. In contrast, in Europe little information is available about potentially inappropriate medication use and is based on small studies with uncertain generalizability. OBJECTIVE: To estimate the prevalence and associated factors of potentially inappropriate medication use among elderly home care patients in European countries. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study of 2707 elderly patients receiving home care (mean [SD] age, 82.2 [ 7.2] years) representatively enrolled in metropolitan areas of the Czech Republic, Denmark, Finland, Iceland, Italy, the Netherlands, Norway, and the United Kingdom. Patients were prospectively assessed between September 2001 and January 2002 using the Minimum Data Set in Home Care instrument. MAIN OUTCOME MEASURES: Prevalence of potentially inappropriate medication use was documented using all expert panels criteria for community-living elderly persons (Beers and McLeod). Patient-related characteristics independently associated with inappropriate medication use were identified with a multiple logistic regression model. RESULTS: Combining all 3 sets of criteria, we found that 19.8% of patients in the total sample used at least 1 inappropriate medication; using older 1997 criteria it was 9.8% to 10.9%. Substantial differences were documented between Eastern Europe (41.1% in the Czech Republic) and Western Europe (mean 15.8%, ranging from 5.8% in Denmark to 26.5% in Italy). Potentially inappropriate medication use was associated with patient's poor economic situation (adjusted relative risk [RR], 1.96; 95% confidence interval [CI], 1.58-2.36), polypharmacy (RR, 1.91; 95% CI, 1.62- 2.22), anxiolytic drug use (RR, 1.82; 95% CI, 1.51-2.15), and depression (RR, 1.29; 95% CI, 1.06-1.55). Negatively associated factors were age 85 years and older (RR, 0.78; 95% CI, 0.65-0.92) and living alone (RR, 0.76; 95% CI, 0.64-0.89). The odds of potentially inappropriate medication use significantly increased with the number of associated factors (P<.001). CONCLUSIONS: Substantial differences in potentially inappropriate medication use exist between European countries and might be a consequence of different regulatory measures, clinical practices, or inequalities in socioeconomic background. Since financial resources and selected patient-related characteristics are associated with such prescribing, specific educational strategies and regulations should reflect these factors to improve prescribing quality in elderly individuals in Europe.

• MeSH
• geriatrie statistika a číselné údaje   MeSH
• lidé MeSH
• logistické modely MeSH
• medikační omyly statistika a číselné údaje   MeSH
• průřezové studie MeSH
• retrospektivní studie MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• služby domácí péče statistika a číselné údaje   MeSH
• spotřeba léčiv statistika a číselné údaje   MeSH
• Check Tag
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• práce podpořená grantem MeSH
• Geografické názvy
• Evropa MeSH

OBJECTIVE: The aim of this paper is a complex evaluation of clients medication in the geriatric care facility Domov Vlčí mák (DVM) with regard to the most common drug related risk factors in elderly. The paper shows ways of identification, resolution and prevention of drug related problems from the perspective of a clinical pharmacist. METHODS: The medication was evaluated in 74 DVM clients. The sample consisted of 45 women (61 %) and 29 men (39 %) with an average age of 90 years. The project took place in the period from April to June 2020. Patients pharmacotherapy was graded as low, medium or high risk in accordance with the methodology and concept of clinical pharmaceutical care in the Czech Republic developed by the Czech Professional Society of Clinical Pharmacy ČLS JEP. For all clients, medication was also assessed in terms of the risk of falls. RESULTS: There was a total of 62 (84 %) high, 4 (5 %) medium and 8 (11 %) low risk clients. A plan for medication adjustments was proposed for a total of 67 clients in the form of pharmacotherapeutic recommendations. A total of 170 drug related problems was identified and pharmacotherapeutic intervention was performed. The most common problem (in 42 % of cases) was a missing drug in terms of effective therapy. Medication discontinuation was recommended in 33 % of cases, mainly due to the risk of side effects, missing indications or drug necessity. Inadequate dosing was found in 15 % of cases, usually it was recommended to reduce the dose to the so-called “senior dose”. In 6 % of cases laboratory testing was indicated and in 4 % of cases timing of the drug administration was changed. CONCLUSION: Identified drug related problems did not represent major errors that could endanger the quality or safety of the healthcare provided. One of the reasons for the good outcome is an established multidisciplinary cooperation in this facility.

• Klíčová slova
• clinical pharmacist, drug related problems, elderly, multidisciplinary approach, multidisciplinary cooperation, polypharmacy, senior,
• MeSH
• farmaceuti MeSH
• lidé MeSH
• nemocnice MeSH
• nežádoucí účinky léčiv * MeSH
• ozbrojené síly * MeSH
• rizikové faktory MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• Check Tag
• lidé MeSH
• mužské pohlaví MeSH
• senioři nad 80 let MeSH
• senioři MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH